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0 <br />• <br />BUILDING PERMIT APPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />EVERETT <br />SUBMITTAL INSTRUCTIONS: See applicable submittal checklist for submittal requirements and number of copies required for review, <br />WASHINGTON then drop off completed application plus all required submittal documents to 3200 Cedar Street 2nd Floor Intake Drop Box. <br />CONTACT INFORMATION: (P) 425.257.8810 l (E) everetteps@everettwa.gov i (W) everettwa.gov/permits <br />(Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br />PROJECT SITE ADDRESS: STREET 431 104th PL SE PARCEL #: 28051900201100 <br />cIN Everett STATE WA ZIP 98208 <br />SUITE/UNIT #: FLOOR #: ADDITIONAL LOCATION INFORMATION (if applicable): <br />TENANTIBUSINESS NAME (if non-residential): <br />LEGAL DESCRIPTION for new construction: Short Plat/subdivision: Section 19 Township 29 Range 05 Lot No.: 4 (attach copy of long legal description) <br />CONTACT INFORMATION <br />OWNER NAME: Shinya Mitsuta, Trust <br />OWNER MAILING ADDRESS: STREET 9952 66th RD, Apt.5J <br />clTY Forest Hills STATE NY ZIP 11375 <br />OWNER PHONE: (917) 832-6823 <br />OWNER EMAIL: mitsutafamily718@gmail.com <br />CONTRACTOR COMPANY NAME: TBD <br />WA STATE CONTRACTOR LICENSE #(REQUIRED): <br />CITY OF EVERETT BUSINESS LICENSE #(REQUIRED): <br />CONTRACTOR ADDRESS: STREET <br />CITY STATE ZIP <br />CONTRACTOR PHONE: <br />CONTRACTOR EMAIL: <br />PRIMARY CONTACT: ❑ OWNER ❑ CONTRACTOR ❑✓ OTHER (Please Specify) Interior Designer <br />CONTACT NAME: <br />Y u m i Ka g a m i h a ra <br />CONTACT PHONE: 646-734-3446 <br />CONTACT EMAIL: yumi@hatanostudio.com <br />BUILDING INFORMATION <br />VALUATION OF WORK: $ 50,000 <br />ASSOCIATED LAND USE PROJECT # (if applicable): <br />(Valuation shall include the prevailing fair market value of all labor, materials, and equipment needed to complete the work, whether actually paid or not.) <br />EXISTING USE OF BUILDING: Residence <br />PROPOSED USE OF BUILDING: Residence <br />HEAT SOURCE: ✓❑Gas ❑Electric ❑Other <br />BUILDING TYPE: ✓❑SFR ❑Townhouse ❑Duplex ❑ADU ❑Multi -Family - # Units: ❑Commercial ❑Accessory Structure <br />TYPE OF PROJECT (check al/ that apply) : []New Construction ❑Addition ❑✓ Remodel ❑Repair ❑T.I. ❑Change of Use <br />❑Modular ❑Portable ❑Re -roof ❑Exterior Alteration ❑Tank (above ground) ❑Accessory Structure <br />❑Fence over 7ft high ❑RackStorage ❑Pool/Hot Tub ❑Tank (above ground) ❑Other: <br />DESCRIPTION OF WORK: <br />Interior remodel of house. Removing some non-structural walls for layout change. <br />ACKNOWLEDGEMENT.• i have reviewed this application and confirm the information contained herein is true and correct. Work done pursuant to this permit must comply with <br />current federal, state, and local law. The granting of a permit only authorizes approved work and no deviations therefrom. Deviations must first be authorized in writing from the <br />Building Official before being authorized under any circumstance. l am the owner, or l am authorized by the owner of this property to perform the work for which application is made, <br />and l comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br />City of Everett Official Use Only <br />PERMIT # b 2 1 0 01 0 2-08/24I2021 <br />Owner/Authorized Agent Signature Date (Revised 21812021) <br />